REPORT OF SAMPLE ANALYSIS by gxr14046

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									                                                                                                                                              Laboratory ID #: 48162 

                       SAN ANTONIO RIVER AUTHORITY                                                                                            600 E. Euclid Ave 
                                                                                                                                              San Antonio, TX 78212 
                    REGIONAL ENVIRONMENTAL LABORATORY                                                                                         Phone:  210‐227‐1373     Fax:  210‐302‐3694    
                                                                                                                                              www.sara‐tx.org  

DRINKING WATER (P/A) COLIFORM REQUEST & CHAIN OF CUSTODY FORM
                   Public/Private Water System Identification & Sample Collection Information                                    LABORATORY USE ONLY – DO NOT WRITE BELOW
 Public Water System
                                   /     /     /    /      /     /                   System Type                                           Client Notification Unsuitable or Postive Sample
 ID:
 P W S Name :                                                                                                                  Sampler/Person Contacted:
 P W S County:                                                                  Public              Private                    Date/Time Notified:
 Name :                                                                                                                        *Replacements / Re-test Samples within 24 hours: Yes or No
 Address         :                                                                  Water Source                               This analytical report is intended exclusively for the individual or entity to which it is
 City, State Zip :                                                                                                             addressed. If you are not the named addressee, you are not authorized to read, print, retain,
                                                                                                                               copy, or disseminate this report or any part of it. If you have received this report in error,
 Phone Number:                             Fax:                             Groundwater          Surface Water                 please notify the San Antonio River Authority.

    Owner               Operator         Other:
 Sampler Name:                                               Contact#                                                          Report
 Alternate Contact Name:                                     Contact#                                                          Approved by:                                                       Date:
                                                                                                                   Chlorine                                               Lab Results – Test Method                 Unsuitable
      Sample Identification/Location      Collected                            Sample Type
                                                                                                                   Res: mg/l                                              SM9222 B         SM9223 B                  Sample*
                                                                                                                                                            Temp      (Membrane Filter)      (Enzyme Substrate)
                                                                                             Repeat                              Sample Number
 Use Specific Address/Location:                                                                                      Free                                   °C
  NOT SITE #                                                                                 Replacement                                                              Total Coliform               E. coli           Rejection
 (Raw Wells Use Source ID for Well                                                           Sample # for                                                                                                            Criteria *
                                                                            Raw                                      Total
 Sampled)                                                                                    Previous                                                                  Present    Absent      Present    Absent
                                       Date           Time     Rout   Con   Well   Special   Positive/Unsuitable


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                                                       Chain of Custody                                                                       *Unsuitable Sample for Analysis – Rejection Criteria

 Relinquished By:                                                Date:                           Time:
                                                                                                                               1) Sample too old. Not received within              4) Chlorine residual
 Received By:                                                    Date:                           Time:                            30 hours of collection                           5) Sample leaked in transit.
                                                                                                                               2) Quantity insufficient for analysis (100          6) Heavy SILT/ BACTERIA/
 Relinquished By:                                                Date:                           Time:                            mL. required)                                       TURBIDITY PRESENT (circle)
                                                                                                                               3) Form incomplete / date discrepancy               7) Other DESCRIBE:
 Received By:                                                    Date:                           Time:                            (Circle Errors)

F151_Rev02                                                                                    Effective: 05/01/2009                                                              Page 1 of 1

								
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